How Hypogonadism Is Diagnosed

Hypogonadism occurs when insufficient amounts of sex hormones—androgens in males and estrogen in females—are produced in the gonads of males (in the testicles of the scrotum) and ovaries of females. It can arise due to a range of factors, including aging, endocrine disorders, genetics, cancer treatments, and medications.

Symptoms of hypogonadism vary based on age and sex at birth, ranging from delayed puberty in children to low sex drive, erectile dysfunction, irregular menstruation, hair loss, and fatigue in adults.

Diagnosing hypogonadism can be challenging as this condition presents differently based on your sex at birth and age. It also involves determining the underlying cause or causes of the issue. To do this, doctors may rely on physical and pelvic examinations, blood tests, imaging techniques, such as magnetic resonance imaging (MRI) or sonography, and semen analysis, among other techniques.

With timely and accurate diagnosis of hypogonadism, treatment can be tailored to take on the condition.  

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At-Home Testing

For both males and females at birth, there are at-home hormone testing kits available over the counter. With these, you send samples of your saliva or blood to a lab for clinical evaluation.

The two primary types of tests are:

At-home estrogen tests: For women, these assess levels of estradiol (an important precursor to estrogen), cortisol, and testosterone, among other hormones. Many kits are available, with results typically returned within a week of receipt of blood and/or saliva samples.^[6] Popular types include Everlywell's Women's Health Test and the LetsGetChecked Female Hormone Test.
At-home testosterone tests: A range of companies, including Everlywell and Imaware, manufacture testing kits that measure testosterone and other important hormones, such as thyroid stimulating hormone and cortisol. Both "free testosterone," the type that's unattached to proteins, and total testosterone levels can be evaluated using blood or saliva samples sent to a laboratory.

Depending on the manufacturer, results may be as reliable as tests taken in the hospital or clinic. Talk to your doctor about testing kits that would work for you, and what results might mean.  

Physical Examination

If you suspect hypogonadism, the first step in diagnosis involves an in-person physical evaluation, usually conducted by a urologist or your primary care physician. This can involve:

Assessment of symptoms: The evaluation begins with a discussion of any signs and symptoms. This may mean discussing irregular menstruation in females and erectile dysfunction and low sex drive in males.
Physical examination: In adolescents, the telltale sign of hypogonadism is delayed onset of puberty, so doctors assess level of breast development, pubic hair growth, and other features. Manifestations of the condition in adult males, such as gynecomastia (breast development) and loss of muscle mass, are assessed, and adult females may undergo a pelvic exam.
Health check: Many conditions can affect sex hormone levels, so routine evaluation of health metrics, such as blood pressure and heart rate, are taken. Age is also a factor. As you get older, your levels of sex hormones naturally go down.
Medications: Since hypogonadism can also be a side effect of medications like opioids and corticosteroids, you'll be asked about the prescription and over-the-counter (OTC) drugs you're taking.

Family history: Several genetic conditions, such as Kallmann syndrome, can cause hypogonadism. While these issues aren't always inherited—many arise due to spontaneous chromosomal abnormalities—you may be asked if family members have ever had certain health issues.

Labs and Tests

The only way to confirm the presence of hypogonadism is through an assessment of levels of sex hormones and their precursors in the blood. Blood work for this condition entails measuring these levels and, in some cases, looking for other potential causes of the condition. Given their hormonal differences, specific tests—and desired results—vary between women and men.

Estrogen

There are several kinds of estrogens, but three are of particular importance: estrone (E1), estradiol (E2), and estriol (E3). Estrone is produced once menopause has started to set in (at around age 50), estradiol is primarily produced in nonpregnant women, and estriol, which is associated with pregnancy.

Testosterone

Usually, testosterone, the principal male sex hormone (or androgen), is attached to proteins in the blood, but some is "free," or unattached. Clinical tests provide measures of overall levels and free testosterone, both of which are effective at identifying hypogonadism in males.

Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH)

FSH and LH are produced in the pituitary gland (a small gland located at the base of the brain that regulates the activity of other glands) and play an essential role in both androgen and estrogen production. High levels in men and women can mean insufficient sex hormones, and low levels in children occur when puberty is delayed.

LH Response to Gonadotropin-Releasing Hormone (GnRH)

The hypothalamus of the brain produces the hormone GnRH, which is then secreted by the pituitary gland to regulate female and male reproductive functions. This blood test sees how well LH in the gland is reacting to GnRH and can also assess levels of estradiol in women and testosterone in men.

Basically, after an initial blood sample is taken, GnRH is administered via injection. After some time, doctors collect additional blood samples for testing and comparative analysis.   

Prolactin

Levels of prolactin are naturally elevated when women are nursing but can cause menstruation problems if they're too high. In adult males, excess prolactin may cause lactation and be a sign of hypogonadism. This test is also used to diagnose prolactinoma, the growth of a tumor on the pituitary gland that can limit or stop sex hormone production.

Thyroid Hormones

Since problems with the thyroid gland can cause some of the same symptoms as hypogonadism, blood work will also assess its function. Low levels of the hormones TSH, T3, and T4 are signs of hypothyroidism (an underactive thyroid), with high levels indicating hyperthyroidism (an overactive thyroid), both of which can affect the pituitary gland.   

In women, these conditions can make menstruation irregular, and in men, they lead to other symptoms associated with hypogonadism, including low sex drive, erectile dysfunction, and gynecomastia.

Other Tests

Several additional tests also may prove necessary to aid in diagnosis. Hemochromatosis, excessive iron in the bloodstream, is a sign of hypogonadism and can be detected using a blood sample. This buildup also causes fatigue, weakness, joint and abdominal pain, among other symptoms.  

Infertility being a symptom in males, semen may be analyzed and sperm counter. Further, chromosomal analysis and genetic testing may be needed to identify congenital causes, such as Klinefelter's syndrome (in males) and Turner's syndrome (in females).    

Imaging

There are two types of hypogonadism. The primary type arises due to problems in the female ovaries or male gonads, while issues in the pituitary gland—usually the development of benign (noncancerous) tumors called adenomas—cause secondary (or central) hypogonadism. Imaging techniques are crucial in assessing underlying causes of the issue, as well as any related problems.

Magnetic Resonance Imaging (MRI)

Magnetic resonance imaging (MRI) relies on magnetic fields and radio waves to create three-dimensional (3D) images of the brain and pituitary gland. Especially effective for the imaging of soft tissues, this type of scan allows doctors to assess any tumor growth either on the gland or surrounding brain regions.

In addition, MRI scans of the pelvic region may be used to aid in the diagnosis of primary hypogonadism due to radiation treatment damage, ovarian problems, or other issues. However, sonography is more often employed.     

Computerized Tomography (CT)

Another means used to examine tumors in or around the pituitary gland, CT scans rely on multiple X-rays to produce images of the area. As with MRI, a 3D representation is produced, allowing doctors to track growth and assess if any adenomas or other issues are impacting function.

Sonography

In addition, when female hypogonadism is believed to be primary, or arising due to problems in the ovaries, sonography, or ultrasound, is used. This type of imaging relies on ultrasound waves bouncing off structures in the body to get a picture of the pelvic area. Most often used for prenatal imaging, this scan may be recommended  

Differential Diagnosis

There are many factors that can lead to hypogonadism. Along with natural decreases in levels of sex hormone production as you age, a wide range of other conditions can be associated with it. Further, its symptoms may arise in other diseases, which may require individualized treatment.

As such, when hypogonadism is detected, additional blood work and testing may be necessary to determine its causes. This lets doctors rule out or identify other conditions and to tailor treatments to manage any co-occurring conditions.

This means screening for a number of conditions, including:

Endocrine disorders, such as type 2 diabetes mellitus or Addison's disease, can impact function of the gonads and ovaries, leading to primary hypogonadism. Type 2 diabetes is the difficulty in the way the body regulates and uses sugar as fuel, while Addison's disease is an underproduction of hormones in the adrenal glands.
Liver diseases, such as cirrhosis or liver failure (due to hepatitis, chronic liver disease, or other factors), can cause hypogonadism. Blood panels assessing liver function, then, are a standard part of diagnosis.
Thyroid problems, such as having an overactive thyroid (hyperthyroidism) or underactive thyroid (hypothyroidism), can influence hormone production. These irregularities can cause similar symptoms, so diagnosis involves checking on the health of this gland as well.
Prostate cancer can also affect hormone levels. Screening for this, the most common cancer in men, is recommended when low testosterone is present or there are other signs of hypogonadism.
Osteoporosis is a weakening of the bones that can arise due to low testosterone levels. It's often associated with hypogonadism and requires separate treatment. As such, doctors may also want to perform bone density tests.

Human immunodeficiency virus (HIV/AIDS) is a major risk factor for secondary hypogonadism, and the conditions share many symptoms. Though effective therapies have reduced cases of co-occurrence of these two conditions, there's still a robust association. Screening for this chronic, degenerative sexually transmitted infection is nonetheless recommended.

A Word From Verywell

While finding out you have low testosterone or estrogen can be jarring, it's important to remember that there's a lot you can do to successfully manage hypogonadism. Surgeries removing adenomas from the pituitary gland can reverse symptoms, and hormone replacement therapies are effective in chronic cases. With treatment—alongside other healthy lifestyle changes—people with this condition can lead happy and productive lives.   

Most important in managing hypogonadism is being proactive about seeking help. If you suspect you or your child is experiencing symptoms, don't hesitate to call your doctor. As is often the case, the sooner you can detect and treat hypogonadism, the better off you'll be.    

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